Supporting the least able in sanitation improvement (part 2)

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We then moved up to the Tagaytay highlands, a beautiful area Southwest of Manila on the banks of Taal lake overlooking its volcano, for a three-day workshop that brought together practitioners, thinkers and researchers on CLTS and sanitation development from around the region and from further afield. Participants presented their experiences in the provision of support to the least able for sanitation and hygiene improvement from Nepal, Cambodia, Vietnam, Timor-Leste and the Philippines. Other participants shared learning from the SNV Sustainable Sanitation and Hygiene for All (SSH4A) programme being implemented in six countries in Asia; from a recent multi-country study on Equity, Inclusion and Non-Discrimination (EQND) for the Global Sanitation Fund; and from broader WaterAid, UNICEF and IDS experiences around the world.

GSF study on equity, inclusion and non-discriminationWe were also joined by the inimitable Dr Kamal Kar and Robert Chambers, which added a strong CLTS flavour to the proceedings. The GSF study on EQND provided a firm basis for the workshop discussions – highlighting the realities of the least able (or “potentially disadvantaged” – the term preferred by the EQND authors), and the many ways in which approaches that do not involve and give voice to the diversity, skills and capacities of the least able can have unintended and often unrecognised consequences.

The goal of the workshop, which was to pull together and discuss regional knowledge on how best to support the least able in sanitation and hygiene improvement, proved challenging. Not least because there was some reluctance (particularly among the stronger CLTS advocates) to accept that CLTS has often fallen short among the least able, and that even an improved CLTS approach (with the explicit intention of involving and giving voice to the least able) is unlikely to be enough when the goal is for large-scale and sustained improvement.

CLTS for increased equity and inclusionCLTS has been enormously successful in triggering large-scale sanitation behaviour change, and is far more inclusive than other approaches – as by its nature, CLTS aims to ensure that everyone in the community spots practising open defecation, and improves their sanitation behaviour.

However, not all triggered communities become Open Defecation Free (ODF) – the ODF success rate remains below 50% in some countries, which means that a significant proportion of communities have not gained the assumed benefits of CLTS (the elimination of open defecation, the public health benefits associated with the reduction in excreta-related pathogens in the local environment, and the other social benefits from linked to more dignified, safe and convenient sanitation and hygiene practices).

Furthermore, ODF sustainability studies reveal that sustained ODF outcomes remain an elusive goal. Most ODF communities suffer some amount of reversion to open defecation, or some partial usage of toilets (whereby some members of the household do not like to use the toilet; or revert to open defecation when the toilet is busy); and where the CLTS implementation has been weak, the reversion rates are sometimes high.

Recognition of these problems of scale, of local governance and local politics, and the socio-economic and socio-cultural realities of rural communities is important. These local problems and realities mean that some proportion of rural communities and local governments will not do the right thing, will not provide support to those in need, and will not monitor outcomes well or respond to problems.

Even the best facilitation and participatory approach will not solve all of these internal and local problems in all places and, therefore, outsiders need to check on outcomes, and examine carefully whether the least able are really benefitting from sanitation and hygiene improvement. If these groups are not benefiting, then many of the arguments for public investment in CLTS and other forms of sanitation support are greatly weakened – the disease burden, and other social costs, are strongly concentrated in the least able (and most vulnerable and marginalised), thus any failure to reach these groups has significant negative impacts on public health and on the benefits realised.

External support optionsWhere we have good evidence (from more widespread and targeted sustainability monitoring as well as research into equity and inclusion) that the least able are not being adequately supported, and that their outcomes are worse than those in other less critical groups, we have to consider alternative forms of support. While we all hope that CLTS processes with a more intentional focus on equity and inclusion will generate some improvements and benefits, it seems unlikely that these improvements will provide more than incremental gains on what has already been achieved. ODF success rates and sustainability rates may improve, yet it is likely that there will still be some groups and areas in which the least able are not reached, or are not able to sustain improved sanitation and hygiene practices over time.

Unfortunately, little time was spent at the workshop examining alternative forms of support in any detail, including the big family of sanitation finance options, such as targeted toilet vouchers, rebates, hardware subsidies, conditional cash transfers, microfinance and so on. There is never enough time at these events to cover everything, and with the CLTS discussions consuming much of the energy and time available to the group, little serious discussion was held on these alternative or external forms of support.

Another factor was the limited comparative evaluation of all the different forms of external support – for example, the Philippines has produced a host of interesting cases of different mechanisms and approaches implemented by different partners, in both humanitarian and development contexts. Some of these mechanisms had been described and summarised by UNICEF Philippines; but there was little evidence shared on the relative outcomes of the different mechanisms and approaches, for instance whether some approaches were better than others are reaching the least able, or whether some were more cost-effective and scalable than others. The PhATS approach encourages a multiplicity of approaches for the achievement of common outcomes across large and diverse areas, but it is important that the lessons learned from these experiences are captured and shared, so that we can build the evidence base on what has worked, or not, and revise and improve policy frameworks, incentives and systems for sanitation and hygiene improvement (and for reaching the least able).

The one related issue on which most participants agreed was that, wherever possible, external support should be delayed until the post-ODF phase. Internal solutions, including community support to the least able, and local government support, were the most highly favoured responses, with growing recognition that few CLTS processes succeed without some form of subsidy or support. But where this support is provided and targeted by the community, or the village government, then there is a far greater chance that it will be appropriate, targeted, utilised and monitored. And where external support is required, due to local resources or capacity being unable to provide the type of support required for sustained improvements among the least able, then delaying this support until after ODF verification, and aligning it with existing policies and processes, will greatly reduce the risk that this support undermines community and other market-based support (e.g. sanitation marketing).

In a few countries, notably Nepal and Cambodia, participants noted that achieving ODF status remains a big challenge, in part due to the toilet standards imposed by national governments, which require that even poor and less able households have to build toilets using market-bought components (e.g. pour-flush pans, concrete slabs and lined pits in Nepal). In these situations, some local governments and implementing agencies have resorted to “delayed support”, which is only offered once sanitation coverage passes some threshold value, in the understanding that earlier support may undermine sanitation demand and self-provision. The GSF EQND study reported that these delays, and the desire to avoid mentioning this support until the end of the process, put unreasonable and unnecessary pressure on the least able. The workshop group agreed that more transparent approaches were preferable wherever possible, with clear information provided on eligibility and provision of external support wherever possible. But it was also recognised that “delayed support” was introduced to tackle the realities of sanitation and hygiene improvement in these difficult contexts, and that some situations may require different approaches.

The main output of the workshop was a set of emerging principles on support for the least able in sanitation and hygiene improvement. The emerging principles were put together fairly quickly at the end of the workshop, in an effort to synthesize the wide-ranging discussions, with the aim of providing a starting point in a much longer process of detailed consultation and work with other stakeholders.

The first two principles highlighted the importance of involving the least able in this sort of discussion, and of involving and linking with bodies that represent and work with potentially disadvantaged groups (not least because these groups have long experience in policy discussions of this nature). None of these groups were present at the workshop, but representatives of a child disability support group in the Philippines attended the national forum in Manila on 29 May. Hopefully, the involvement of these groups, and a stronger involvement from the local governments that have achieved improved sanitation outcomes using their own capacity and resources, will be central to this process moving forward!